Hindawi BioMed Research International Volume 2020, Article ID 5319640, 6 pages https://doi.org/10.1155/2020/5319640

Research Article A Radiographic Study of Biomechanical Relationship between the and

Genrui Zhu, Zhifeng Wang, Chengjie Yuan, Xiang Geng, Chao Zhang, Jiazhang Huang, Xu Wang , and Xin Ma

Department of Orthopedics, Huashan Hospital, Fudan University, No. 12, Middle Wulumuqi Road, Jingan District, Shanghai, China

Correspondence should be addressed to Xu Wang; [email protected]

Received 14 September 2019; Revised 12 December 2019; Accepted 25 January 2020; Published 18 February 2020

Academic Editor: Ali Nokhodchi

Copyright © 2020 Genrui Zhu et al. 0is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Previously, scholars have concluded that the Achilles tendon and the plantar fascia were closely biomechanically related, although there is little clinical evidence of the relationship between the two. To investigate the biomechanical relationship between the Achilles tendon and the plantar fascia, the author used standing lateral ankle radiographs of patients with insertional Achilles tendonitis to determine the biomechanical relationship between the Achilles tendon and plantar fascia. Methods. 0e author collected standing lateral ankle radiographs from patients with insertional Achilles tendonitis who accepted surgical treatment in the author’s hospital from March 2009 to July 2018. According to whether there were bone spurs on the posterior side of the calcaneus, patients were divided into group A (spur present on the posterior side) and group B (spur not present on the posterior side). 0e positive rates of spurs on the plantar side of the calcaneus were determined in group A and group B. 0e chi- square test was used to compare the measurement results between the two groups. Results. In group A, 13 were positive for calcaneal bone spurs, and the positive rate was 65.0%. In group B, 3 heels were positive for plantar calcaneal spurs, and the positive rate was 12%. Among all 16 patients with positive plantar calcaneal spurs, 13 had posterior calcaneal spurs (accounting for 81.3%), and 3 had negative results, accounting for 18.7%. 0ere was a significant difference between the results in groups A and B (P < 0.05). Conclusion. 0ere is a relationship between posterior calcaneal spurs and plantar calcaneal spurs in patients with insertional Achilles tendonitis, which can be inferred as resulting from the increasing tension in the biomechanically complex relationship between the Achilles tendon and the plantar fascia.

1. Introduction the risk of Achilles tendon degeneration and insertional Achilles tendonitis [10]. Further, if the Haglund deformity, pain includes pain on the plantar side of the calcaneus insertional Achilles tendonitis and retrocalcaneal ap- and in the posterior heel [1]. Plantar heel pain is often caused pear, then it is known as Haglund syndrome. by plantar , with its typical symptom of pain at the In the current clinical work, it was anecdotally found that medial calcaneal tubercle that is aggravated after standing patients with plantar heel pain who were diagnosed with for long periods of time or running [2–5]. Bone spurs at the often presented with posterior heel pain. Due medial calcaneal tubercle is a typical finding on the X-rays of to an anatomical connection between the Achilles tendon, the plantar heel pain patients, and they can be the mechanical plantar fascia, and the calcaneal, we proposed a hypothesis factors inducing the occurrence of plantar fasciitis [5–7]. that the Achilles tendon, the plantar fascia, and the calcaneal Posterior heel pain is often caused by insertional Achilles were three parts of a biomechanical complex. And in the tendonitis, often combined with the Haglund deformity [8, 9]. high-tension state of this complex, like in the insertional 0e Haglund deformity is an abnormal cystic projection above patients, not only the pain appeared on the the posterior calcaneus, which can cause a high pressure state both sides of calcaneal, but the compensatory bone spurs on its rear structure, lead to , and increase caused by high tension were found bilaterally also [11, 12]. 2 BioMed Research International

In the past, the development of bone spurs on both Since Haglund deformity was believed to have a rela- sides of the calcaneus in patients with Achilles tendinop- tionship with insertional tendinitis, the following various athy and Haglund syndrome has been observed. Fiamengo measurements were also made: the Fowler-Philip angle, as et al. found that the rate of spurs on the posterior side of the shown in Figure 2, the parallel pitch lines, as shown in calcaneus in patients with Achilles reached Figure 3, and the presence of a posterior calcaneal spur, as 44% and the rate of plantar spurs in the same population shown in Figure 1 [17–19]. 0ere was a flowchart to show was 6.3% [13]. In a population with Haglund syndrome, the how the study was conducted, as shown in Figure 4. rate of posterior calcaneal spurs was 57% and the rate of 0e chi-square test was applied to compare the mea- plantar spurs was 16% [14]. Menz et al. found that 55% of surements between the two groups, with the P value set at patients had radiographic evidence of plantar spurs, among 0.05 for statistical significance. whom 56% had an Achilles tendon spur [15]. To further clarify the relationship between plantar spurs and Achilles 3. Results tendinopathy, Vulcano et al. found that 41.9% of the 785 patients diagnosed with Achilles tendinopathy in outpa- According to the inclusion and exclusion criteria, 43 patients tient clinics had plantar spurs [16]. with insertional Achilles tendonitis were enrolled in the Although the rates of bone spurs on the posterior and study group, with 2 having bilateral Achilles tendonitis, so a plantar sides of the calcaneus were observed in previous total of 45 cases of insertional Achilles tendonitis were studies, these studies did not explore the possibility of spurs collected, as shown in Table 1. Of the 43 patients, 37 were appeared simultaneously on both sides of calcaneal in the men (86%), and 6 were women (14%), with an average age of high-tension state of this biomechanically complex. 40.7 (range 15 to 69) years. 0ere were 15 left heels (34.9%), 0e aim of this study was to demonstrate the biome- 26 right heels (60.5%) and 2 bilateral heels (4.7%). chanical relationship between the Achilles tendon and the 0ere were 19 subjects with 20 heels in group A, which plantar fascia by comparing the probability of developing consisted of 14 men and 5 women, with an average age of bilateral calcaneal spurs with that of developing unilateral 46.0 ± 12.4 years (range from 17 to 69 years old). 0ere were calcaneal spurs in the high tension state. So the author ret- 24 subjects with 25 heels in group B, which consisted of 23 rospectively reviewed patients with insertional Achilles ten- men and 1 woman, with an average age of 36.9 ± 15.0 years dinitis who received surgical treatment in the author’s hospital (range from 15 to 65 years old). and analyzed the bone structure data from standing lateral In group A, calcaneal plantar spurs were present in ankle radiographs. 65.0% (13 out of 20) of the heels with calcaneal posterior spurs, while in group B, calcaneus plantar spurs were present 2. Method in 12.0% (3 out of 25), as shown in Figure 5. Calcaneal plantar spurs were found in 16 out of 45 heels, of which 13 0e study was a retrospective radiographic review of patients had posterior spurs (81.3%), as shown in Figure 6. However, with insertional Achilles tendinitis who were admitted for when the plantar spurs were negative (29 out of 45 heels), operations at the orthopedic department in Huashan there were only 24.1% of heels (7 out of 29) presenting Hospital of Fudan University (Shanghai, China) from March posterior spurs, as shown in Table 2. 0ere were significant 2009 to July 2018. 0e inclusion criteria for the study differences between the two groups (P < 0.05). 0e rate of consisted of patients with a diagnosis of insertional Achilles spurs presenting on both sides of calcaneus was 28.9% (13 tendinitis. 0e diagnosis was made by the senior author out of 45). based on his clinical examination and radiographic review In 45 cases of insertional Achilles tendonitis, the positive and was reassured by surgical pathology. All patients had rate of parallel pitch lines was 75.6% (34 out of 45). 0e mean lateral view standing radiographs taken of the ankle. Fowler-Philip angle was 51.39 ± 7.85 degrees. 0ere was only Patients were excluded from the study group if they had one heel in which the Fowler angle was more than 75 degrees previous Achilles tendon surgery or had noninsertional (88°). Achilles tendinitis. 0e present study was approved by the Institutional Review Board of our institutions, and informed 4. Discussion consent was obtained from all participants. According to whether there were bone spurs on the Pain in the heel includes pain on the plantar side of the posterior side of the calcaneus, patients were divided into calcaneus and posterior heel pain [9, 20, 21]. In the current group A (spur was present on the posterior side) and clinical work, it was anecdotally found that patients with group B (spur was not present on the posterior side), as plantar heel pain often presented with posterior heel pain shown in Figure 1. 0en, the author evaluated and [22]. Calcaneal spurs are outgrowths of bone into tendon compared the occurrence of plantar calcaneal spurs be- and ligamentous attachments, appearing mainly at two tween groups A and B. All lateral radiographs were points: one at the posterior aspect of the calcaneus near the reviewed on a picture archiving and communication insertion of the Achilles tendon and the other on the inferior system by three orthopedic surgeons to identify calcaneal aspect of the calcaneus, coinciding with the insertion of the spurs. Patients were considered to have a bone spur only if posterior fibers of the long plantar ligament. it was grossly visible without magnification on the stan- After analyzing imaging studies, the author concluded dard lateral radiograph. that there was a relationship between plantar calcaneal spurs BioMed Research International 3

(a) (b) (c)

(d) (e) (f) (g) Figure 1: Examples of X-ray obtained in the study. (a) no plantar calcaneal or posterior calcaneal spur; (b, c): posterior calcaneal spurs only; (d, e): plantar calcaneal spurs only; (f, g): spurs on bilateral sides of the calcaneus.

Figure 2: 0e Fowler–Philip angle was measured between an inferior line which was tangent to the inferior margin of the cal- caneocuboid joint and the plantar tuberosity of the calcaneus and a Figure 3: 0e Parallel patch lines were obtained by first drawing superior line which was tangent to the posterior prominence at the the inferior line from the inferior margin of the calcaneocuboid insertion of the Achilles tendon. Normal range is between 44 and 69 joint to the plantar tuberosity of the calcaneus. 0en the superior degrees, measurements greater than or equal to 75 degrees were line was drawn parallel to the inferior line beginning at the pos- thought to be consistent with Haglund’s deformity. terior margin of the subtalar joint. If the posterior calcaneal prominence was located above the superior line, it was considered and posterior calcaneal spurs in heels with insertional abnormal and consistent with Haglund’s deformity. Achilles tendinitis. With regard to plantar calcaneal spurs, group A (posterior spurs were positive) was 5 times more probability of developing spurs on both sides of calcaneus likely than group B (posterior spurs were negative) to have was much greater than that of developing unilateral calca- spurs (65% compared to 12%, P < 0.05), as shown in Fig- neal spurs. Moreover, an anatomical connection between the ure 5. Since the mechanical stimulation of plantar calcaneal Achilles tendon and the plantar fascia makes the relation- spurs can lead to plantar fasciitis, which can cause patients to ships among the plantar fascia, calcaneus, and Achilles develop heel pain [21], so we thought it was worthwhile for tendon biomechanically complex, so we assumed this podiatrists to pay attention to calcaneal plantar spurs and the structure may transfer stress from one side of calcaneus to high tension state of the plantar fascia in patients with in- another. Some studies also found that Achilles tendinopathy sertional Achilles tendinitis in the clinical setting. In patients and heel pain can collectively benefit from similar conser- with calcaneal plantar spurs, the positive rate of posterior vative and surgical treatments by reducing the tension on calcaneal spurs reached 81.3%, which was far greater than both sides, such as eccentric calf stretching and gastroc- that in patients without plantar calcaneal spurs (24.1%), as nemius recession [2, 23, 24]. 0erefore, the Achilles tendon, shown in Figure 6. 0ese results indicated that the calcaneus, and plantar fascia should be considered as a whole 4 BioMed Research International

Patients with insertional Achilles tendinitis

Previous Achilles tendon surgery or noninsertional Lateral view Achilles tendinitis standing radiographs of ankle

Excluded from study group Measurements Study group

Spur: present on Fowler–Philip angle, Spur: not present on posterior side parallel pitch lines posterior side

Group A Group B

Measurements Measurements

Presence of posterior Presence of posterior calcaneal spur calcaneal spur

Compare

Conclusion

Figure 4: A flowchart to show how the study was conducted.

Table 1: Patient profiles in group A and group B. Patient numbers Heel numbers Patient group Male Female Total Average age (years) Left Right Bilateral Total Group A 14 5 19 46 ± 12.4 5 14 1 20 Group B 23 1 24 36.9 ± 15.0 10 12 1 23 Total 37 6 43 40.9 ± 14.5 15 26 2 43

20 20 13 (65.0%) 10 13 (81.3%) 10 3 (12.0%) 7 (24.1%) 0 0

7 (35.0%) 3 (18.7%) 10 Plantar spurs 10 Posterior spurs

20 22 (88.0%) 20 22 (75.9%) 30 Positive Negative 30 Posterior spurs Positive Negative Plantar spurs Positive Negative Positive Negative Figure 5: Plantar spurs were present in 65.0% (13 out of 20) of the heels with calcaneal posterior spurs, while there were only 12.0% of Figure 6: 0ere were 16 out of 45 heels presenting plantar spurs, of heels presenting plantar spurs in the posterior spur negative group. which 13 had posterior spurs (81.3%). However, when the plantar Plantar spurs and posterior spurs were inclined to appear at the spurs were negative, there were only 24.1% of heels presenting same time (65.0%) or would not appear at all (88.0%). posterior spurs. BioMed Research International 5

Table 2: 0e presence of calcaneal plantar spurs in group A and diseases were not directly investigated in this study. For this group B. Positive means that calcaneal plantar spur is observed on reason, future research can directly target the correlation the radiograph; negative means that calcaneal plantar spur is not between the two diseases with regard to pathogenesis, observed on the radiograph. treatment, and prognosis. Last, the study group only en- Positive Negative Total rolled 43 patients which was a relatively small sample size. Group A 13 7 20 Furthermore, there was only 1 female patient in group B, and Group B 3 22 25 there were 5 female patients in group B. As far as we Total 16 29 45 concerned, the main reason was because there were only 24 patients enrolled in group B and 19 patients in group A, so it was the small number of patients that caused sampling error. entity, and the pain on both sides of calcaneus must be treated simultaneously. 0erefore, the other side should 5. Conclusion receive equal attention when podiatrists encounter pain on either side of calcaneus in clinical work because of this First, through weight-bearing lateral ankle X-rays, a rela- biomechanical complexity. tionship between posterior calcaneus spurs and plantar 0e Fowler–Philip angle was proposed by Fowler and calcaneus spurs in insertional Achilles tendinitis patients Philip in 1945, and the normal range is 44–69° [18]. It is was found, and a biomechanical complex involving the believed when the angle is greater than 75°, the Haglund Achilles tendon, calcaneus, and plantar fascia was deduced. deformity is large enough to cause swelling of the It was suggested that insertional Achilles tendonitis and at the end of the Achilles tendon, insertional Achilles ten- plantar fasciitis should be considered to be related and donitis, and other diseases. However, in this survey, the treated synthetically in clinical practice. Second, the positive author found that patients with severe insertional Achilles rate of the parallel pitch lines was higher in insertional tendonitis whose formal conservative treatment had failed, Achilles tendonitis patients, and the Fowler–Philip angle was the average Fowler–Philip angle was 51.39°, and only 1 not predictive of insertional Achilles tendonitis. patient had an angle greater than 70°. 0is result was in- consistent with Fowler and Philip’s theory. Fiamengo et al. Data Availability also found no difference in the value of the Fowler–Philip angle between the insertional Achilles tendinitis population 0e datasets generated during and/or analyzed during the and a normal population [13, 14, 19]. 0erefore, the author current study are available from the corresponding author does not believe that there is a strong correlation between the on reasonable request. Fowler-Philip angle and the occurrence of insertional Achilles tendinitis. Conflicts of Interest Furthermore, the author found that the positive rate of the parallel pitch line reached 75.6% in the severe cases of 0e authors have no conflicts of interest to report. insertional Achilles tendonitis requiring surgical treatment, but other studies concluded that the false positive rate of Authors’ Contributions parallel pitch lines in insertional Achilles tendonitis cases Genrui Zhu, Zhifeng Wang, and Chengjie Yuan contributed ranged from 15% to 56.8% [14, 25, 26]. 0e author asserts equally to this work. that the heterogeneity of the study populations with regard to the severity of insertional Achilles tendonitis made it infeasible to compare the results of the present study with Acknowledgments previous studies. 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